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Jin Z, Al Qaysi N, Hanna M, Moses V, Spiguel L, Shaw C, Asirvatham JR. Surgical excision versus clinical follow-up: Outcomes of benign intraductal papillomas diagnosed on core needle biopsy. Am J Surg 2024; 233:114-119. [PMID: 38503684 DOI: 10.1016/j.amjsurg.2024.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/24/2024] [Accepted: 02/22/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To compare outcomes between benign intraductal papillomas diagnosed on core need biopsy that were excised (BIP-E) versus those that were followed-up (BIP-F) at our institution. METHODS Patients were identified by an electronic data base search from January 2010 to October 2016. After exclusions, clinical, radiological and histologic variables were evaluated and biopsy and excision slides reviewed. RESULTS 110 BIP from 104 females were analyzed. 84 BIP were excised and 26 BIP were followed up (mean 43.3 months, range 7-93 months).11 patients in BIP-E group had atypia on excision. There were no statistically significant differences between BIP-E with atypia and BIP-E without, except for clinical presentation with pain/discomfort (p = 0.015) in the former. There were no true upgrades to malignancy in both groups on follow up. One patient from each group developed a new breast cancer distant from IP site after nearly 4 years of uneventful follow-up. CONCLUSION Clinical follow up is an oncologically safe alternative for radiologically concordant BIP. Excision may be considered if a diagnosis of atypia would impact surveillence and chemoprevention recommendations.
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Affiliation(s)
- Zhongbo Jin
- Department of Anatomic and Clinical Pathology, HCA Healthcare, USF Morsani College of Medicine, USA
| | - Nada Al Qaysi
- Department of Pathology, University of California, Davis, USA
| | - Mariam Hanna
- Department of Radiology, University of Florida, Gainesville, USA
| | - Viju Moses
- Division of Rheumatology, Department of Medicine, Baylor Scott and White Health, Temple, TX, USA
| | - Lisa Spiguel
- Department of Surgery, University of Florida, Gainesville, USA
| | - Christiana Shaw
- Department of Surgery, University of Florida, Gainesville, USA
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2
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Lou C, Wang W, Zhou B. Treatment Strategy for Breast Benign Intraductal Papilloma: A Meta-Analysis. J Environ Pathol Toxicol Oncol 2024; 43:39-49. [PMID: 38608144 DOI: 10.1615/jenvironpatholtoxicoloncol.2024052888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
Currently, the optimal treatment approach for breast benign intraductal papilloma (IDP) diagnosed via biopsy remains uncertain. There is ongoing debate regarding the feasibility of clinical follow-up and the criteria for selective surgical excision. This study aims to conduct a meta-analysis to determine the rate of upgrade from breast benign IDP and identify predictive factors associated with the conversion of benign IDP to high-risk lesions or carcinoma, which could guide healthcare practitioners in selecting the appropriate clinical treatment strategy. We conducted a comprehensive search across multiple databases (PubMed, Web Of Science, Cochrane Library, and Embase) for studies published between 2012 and 2023 that evaluated upgrade rates and predictive factors of breast benign IDP diagnosed via biopsy. In addition, we included studies that reported on the clinical follow-up of patients with breast benign IDP. In total, 32 studies comprising 7371 cases of biopsy-diagnosed breast benign IDP were included. Among these cases, 720 demonstrated an upgrade to high-risk lesions or carcinoma, resulting in an upgrade rate of 6.94% [95% confidence interval (CI): 3.0-8.0%]. A subgroup of 1713 patients was clinically followed up, demonstrating an average follow-up duration of 30.95 months. Among them, 26 cases experienced an upgrade to high-risk lesions or carcinoma, yielding an upgrade rate of 1.51% (95% CI 0.00-2.00). Furthermore, we identified nine predictive factors associated with the upgrading of breast benign IDP, which included age at diagnosis, personal history of breast cancer, family history of breast cancer, multiple IDPs, lesion size ≥ 10 mm, palpable mass, calcification, and the presence of mass and asymmetry in mammographic findings. Although the conversion rate of breast benign IDP to high-risk lesions or carcinoma is relatively low, timely identification of predictive factors associated with benign IDP upgrades may help selecting the optimal clinical treatment strategy, such as surgery for patients with benign IDP presenting one or more predictive factors, while clinical follow-up for those without specific risk factors.
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Affiliation(s)
- Congkun Lou
- Comprehensive Cancer Center, Nanjing Tianyinshan Hospital, Nanjing 211100, China
| | - Wenhsin Wang
- Xiamen Keli Medical Beauty Clinic, Xiamen 361003, China
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Salisbury T, Gurung A, Koonmee S, Ali L, Ondic O, Bhan R, Pivovarcikova K, Hes O, Alaghehbandan R. Upgrade Rate and Predictive Factors Associated With Breast Papillary Lesions on Core Biopsy: A Canadian Experience. Int J Surg Pathol 2023; 31:1206-1216. [PMID: 36437635 DOI: 10.1177/10668969221137515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Background: Papillary lesions of the breast are a heterogeneous group, encompassing a wide range of lesions. The histologic distinction between papillary breast lesions remains challenging, especially on core biopsy specimens. Aim: This study aimed to determine the rate of upgrade to atypia or malignancy of biopsy-proven papillary lesions on surgical follow-up and to assess for factors associated with an upgrade in Greater Vancouver, BC, Canada. Materials and Methods: This is a retrospective population-based study of all breast papillary lesions diagnosed on core biopsy between 2017 and 2019 in the Fraser Health Authority in Greater Vancouver, Canada. Patients were retrieved from the laboratory information system. Patient demographics, histopathologic, and radiologic findings were analyzed. Results: A total of 269 specimens from 269 patients (mean 61.1 years), including 265 female and 4 male patients, were included in the study. Of the 269 specimens, 129 (48%) were intraductal papillomas and 140 (52%) were atypical papillary lesions. The overall upgrade rate among papillomas was 11.6% (15 of 129) on final excision. The mean age of patients diagnosed with papilloma on core biopsy was significantly younger than those with atypical papillary lesions (55.6 vs 66.1 years, P < .0001). Lesion size in patients with papillomas on core biopsy was significantly smaller than those with atypical papillary lesions (11.1 vs 15.1 mm, P = .001). The upgrade rates in patients <55 and ≥55 years were 4.9% and 13.2%. Size (P = .004) and atypia on core biopsy (P = .009) were significantly associated with upgrade. Older age (>55 years) (OR = 5.3, 95% CI: 1.04-27.08) was an independent predictor of upgrade among papillomas. Size, location, and Breast Imaging-Reporting and Data System (BI-RADS) radiologic categories in our study were not associated with predicting the upgrade of papillomas. Conclusion: Our data suggest that the risk of upgrade to atypia or malignancy is sufficient to warrant the excision of benign papillomas of any size in patients aged ≥55 years. In patients younger than 55 years, observation with close clinical and radiological follow-up without surgery may be sufficient. Our findings also support surgical excision of papillomas diagnosed on core biopsy when associated with atypia.
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Affiliation(s)
- Taylor Salisbury
- Department of Pathology, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Ananta Gurung
- Department of Pathology, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Supinda Koonmee
- Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Leila Ali
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ondrej Ondic
- Department of Pathology, Faculty of Medicine, Charles University, Plzen, Czech Republic
| | - Rohan Bhan
- Department of Medicine, Saba University School of Medicine, The Bottom, Saba, Dutch Caribbean
| | | | - Ondrej Hes
- Department of Pathology, Faculty of Medicine, Charles University, Plzen, Czech Republic
| | - Reza Alaghehbandan
- Department of Anatomic Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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4
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Tierney SN. Intraductal Papillomas. Surg Clin North Am 2022; 102:965-972. [DOI: 10.1016/j.suc.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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5
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Clinical, Radiological and Pathological Correlation of Papillary Lesions of the Breast. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03591-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Corbin H, Bomeisl P, Amin AL, Marshall HN, Gilmore H, Harbhajanka A. Upgrade Rates of Intraductal Papilloma with and without Atypia Diagnosed on Core Needle Biopsy and Clinicopathologic Predictors. Hum Pathol 2022; 128:90-100. [PMID: 35863513 DOI: 10.1016/j.humpath.2022.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
Surgical excision of breast intraductal papilloma (IDP) without atypia diagnosed on core needle biopsy (CNB) is controversial as the risk of upgrade to malignant lesions is not well established. This study investigates upgrade rates of benign and atypical IDP to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) and clinicopathologic predictors. We identified 556 cases of IDP diagnosed on CNB at a single institution from 2010-2020 after excluding patients with a history of breast carcinoma, ipsilateral high-risk lesion, radiologic/pathologic discordance, or less than 2 years of follow-up if no excision within one year. Of these, 97 biopsies were consistent with atypical IDP and 459 were benign IDP. Surgical excision was performed for 318 (57.2%), and the remaining 238 (42.8%) underwent active monitoring. The upgrade rate for IDP without atypia was 2/225 (0.9%; 1 DCIS and 1 IC). Of 93 surgically excised atypical IDPs, 19/93 (20.4%) upgraded (14 DCIS and 5 IC). Of 238 non-excised IDPs followed clinically (range 24-140 months, mean 60 months), there was no subsequent breast cancer diagnosed at the IDP site on follow-up. Mean age of patients was 56 yr±12.6sd without upgrade, 63 yr±10.6sd (p value=0.027) with DCIS, and 61 yr±10.8sd (p value=0.35) with IC. Atypical IDP was more likely to upgrade if biopsied by stereotactic guidance (8/19, 42.1% p=0.035). At our institution, we had an exceedingly low upgrade rate for benign IDP. Overall, patients with upgrade to DCIS were older. For atypical IDP, upgrade was seen in higher proportions of stereotactic biopsies.
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Affiliation(s)
- Haley Corbin
- Case Western Reserve University School of Medicine, 9501 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Philip Bomeisl
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Amanda L Amin
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Holly N Marshall
- Department of Radiology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Hannah Gilmore
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Aparna Harbhajanka
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Park J, Lee NR, Oh HK, Park SH, Kim JK, Jeong YJ. Factors associated with upgrade, malignant upgrade, and subsequent breast cancer occurrence of papillary breast lesions diagnosed on core needle biopsy. Asia Pac J Clin Oncol 2022; 19:e96-e105. [PMID: 35634788 DOI: 10.1111/ajco.13798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/26/2022] [Accepted: 05/08/2022] [Indexed: 11/29/2022]
Abstract
AIM In this study, we analyzed the upgrade rate and associated factors for upgrade, malignant upgrade, and subsequent breast cancer occurrence of papillary breast lesions diagnosed on core needle biopsy (CNB). METHODS One hundred sixty-nine patients who underwent surgery for the treatment of papillary breast lesions diagnosed on CNB were included in this study. Medical records including radiological and pathological reports were retrospectively reviewed. RESULTS The overall upgrade rate was 29.6%, and upgrade rate to malignancy was 16.6%. Age over 45 years, preoperative tumor size ≥0.7 cm on breast ultrasound, pathologic tumor size ≥0.4 cm, breast imaging reporting and data system (BIRADS) category 4b or 4c, and personal history of breast cancer were associated with upgrade. In addition, age over 45 years, preoperative tumor size ≥0.9 cm, pathologic tumor size ≥0.6 cm, atypia in CNB, and BIRADS category 4b or 4c were associated with malignancy. The risk of subsequent breast cancer occurrence was increased in preoperative tumor size ≥0.8 cm, pathologic tumor size ≥0.5 cm, multiple and recurrent lesions. CONCLUSION Our study showed high upgrade rate of papillary breast lesions diagnosed on CNB. Our findings suggest that surgical excision is recommended for papillary breast lesions diagnosed on CNB in selected patients.
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Affiliation(s)
- Junyoung Park
- Department of Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea
| | - Na-Rang Lee
- Department of Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea
| | - Hoon Kyu Oh
- Department of Pathology, Daegu Catholic University, School of Medicine, Daegu, Republic of Korea
| | - Sung Hwan Park
- Department of Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea.,Department of Surgery, Daegu Catholic University, School of Medicine, Daegu, Republic of Korea
| | | | - Young Ju Jeong
- Department of Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea.,Department of Surgery, Daegu Catholic University, School of Medicine, Daegu, Republic of Korea
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Jatana S, Zahra S, Miron AD, Antonacci G, Di Lena É, Thériault M, Meterissian S. A retrospective study evaluating outcomes of surgical excision versus radiologic follow-up of benign breast papillomas without atypia. Am J Surg 2022; 224:932-937. [PMID: 35513913 DOI: 10.1016/j.amjsurg.2022.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/09/2022] [Accepted: 04/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND There is uncertainty whether benign breast papillomas without atypia (BP) can be followed by imaging or require surgical resection. METHODS A single-center, retrospective cohort study of patients diagnosed with BP (2011-2021) to determine the upgrade rate on surgery, and factors associated with surgical intervention and upgrade. RESULTS 139 BPs were included. 27(19.4%) had upfront surgery; 112(80.6%) had imaging follow-up. The upfront surgery group had higher rates of pre-excision nipple inversion (n = 2(8.3%)vs.n = 0(0%),p = 0.003). In the imaging group, the median follow-up was 3.8years, and 9 had subsequent resection. Upgrade rate was 5.8%(8/139). Of all BPs undergoing surgery (n = 36), patients ≥60years (75.0%vs.25.0%,p = 0.049) or with family history of breast cancer (87.5%vs.48.1%,p = 0.048) were more likely to have upgrade. CONCLUSIONS Despite a low number of events, this study supports radiologic follow-up of BP except in patients ≥60 years or with family history of breast cancer, adding to the growing body of evidence supporting watchful waiting of BPs.
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Affiliation(s)
- Sukhdeep Jatana
- Faculty of Medicine, McGill University, Montreal. 3605 Rue de la Montagne Décarie, Montreal, Quebec, H3G 2M1, Canada
| | - Saly Zahra
- Department of Diagnostic Radiology, McGill University University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Alexander-Darius Miron
- Cedars Breast Clinic, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Georgianna Antonacci
- Cedars Breast Clinic, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Élise Di Lena
- Division of General Surgery, Department of Surgery, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Mélanie Thériault
- Department of Diagnostic Radiology, McGill University University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Sarkis Meterissian
- Faculty of Medicine, McGill University, Montreal. 3605 Rue de la Montagne Décarie, Montreal, Quebec, H3G 2M1, Canada; Cedars Breast Clinic, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada; Division of General Surgery, Department of Surgery, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada.
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9
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Zhang X, Liu W, Hai T, Li F. Upgrade Rate and Predictive Factors for Breast Benign Intraductal Papilloma Diagnosed at Biopsy: A Meta-Analysis. Ann Surg Oncol 2021; 28:8643-8650. [PMID: 34331160 DOI: 10.1245/s10434-021-10188-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current standard management for intraductal papilloma (IDP) diagnosed at biopsy indicates complete surgical resection, but there are increasing controversies over whether and when routine excision is indeed necessary. OBJECTIVE The aim of this study was to determine the carcinoma upgrade rate and identify the associated predictive factors for IDP diagnosed at biopsy by meta-analysis. METHODS We searched the PubMed and EMBASE databases for studies published from 2009 to 2020 that investigated the upgrade rate and predictive factors of IDP diagnosed at biopsy. RESULTS A total of 7016 IDP cases diagnosed at biopsy and histologically examined after surgical excision were pooled from 44 original studies. The pooled prevalence of IDP in breast biopsy findings was 4.6% [95% confidence interval (CI) 4.4-4.7%] and the majority of IDP tumors were benign. The pooled upgrade rates to carcinoma for benign IDP and atypical IDP were 5.0% (95% CI 4.4-5.5%) and 36.0% (95% CI 32.7-39.2%), respectively. In addition, we identified 10 predictive upgrade factors for benign IDP, including Breast Imaging Reporting and Data System (BI-RADS) 5, BI-RADS 4C, mass and calcification in the mammographic finding, bloody nipple discharge, imaging-histological discordance, peripheral IDP, palpable mass, BI-RADS 4B, microcalcification, and lesion size ≥ 1 cm. The upgrade rates associated with these predictive factors ranged from 7.3 to 31.1%. CONCLUSION Surgical excision appears a reasonable recommendation for atypical IDP. Patients with benign IDP exhibiting one or more predictive factors might benefit from surgical excision, while patients with asymptomatic benign IDP without these predictive factors can be managed by imaging surveillance.
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Affiliation(s)
- Xiaoli Zhang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenqing Liu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Hai
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Papillary neoplasms of the breast-reviewing the spectrum. Mod Pathol 2021; 34:1044-1061. [PMID: 33462367 DOI: 10.1038/s41379-020-00732-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/15/2020] [Accepted: 11/24/2020] [Indexed: 12/14/2022]
Abstract
Papillary neoplasms of the breast encompass a wide range of tumor types ranging from the benign intraductal papilloma to in situ and invasive papillary carcinomas. In this review, we considered each tumor entity listed under the Papillary Neoplasms category in the latest WHO Classification of Breast Tumors (5th edition), namely intraductal papilloma, papillary ductal carcinoma in situ, encapsulated papillary carcinoma, solid-papillary carcinoma, and invasive papillary carcinoma. We examined their pathological features, current issues pertaining to diagnosis and prognostication, as well as the latest molecular findings. We also briefly addressed adenomyoepithelioma and the newly included tall cell carcinoma with reversed polarity, highlighting areas where they overlap with papillary neoplasms.
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Analysis of 612 Benign Papillomas Diagnosed At Core Biopsy: Rate of Upgrade to Malignancy, Factors Associated with Upgrade, and A Proposal For Selective Surgical Excision. AJR Am J Roentgenol 2021; 217:1299-1311. [PMID: 34008998 DOI: 10.2214/ajr.21.25832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Despite numerous published studies, management of benign papillomas without atypia remains controversial. Objective: To determine the malignancy upgrade rate of benign papillomas, identify risk factors for upgrade, and formulate criteria for selective surgery. Methods: This retrospective study included benign papillomas without atypia diagnosed on percutaneous biopsy between 12/01/2000 and 12/31/2019. Papillomas that did not undergo surgical excision or at least 2 years of imaging and/or clinical follow-up were excluded. Clinical, imaging, and histopathologic features were extracted from the electronic medical record. Features associated with upgrade to malignancy were identified. Multivariable logistic regression was performed. Results: The study included 612 benign papillomas in 543 women (mean age 54.5 ± 12.1 years); 466 papillomas were excised, and 146 underwent imaging/clinical surveillance. The upgrade rate to malignancy was 2.3% (14/612). Upgrade rate was associated (p<.05) with radiology-pathology correlation (50.0% if discordant vs 2.1% if concordant), patient age (5.6% for age ≥60 vs 0.7% for age <60), presenting symptoms (6.7% if palpable mass or pathologic nipple discharge vs 1.3% if no symptoms), and lesion size (7.3% if ≥10 mm vs 0.6% if <10 mm). Three of 14 upgraded papillomas were associated with ≥4 metachronous or concurrent peripheral papillomas. No incidental papilloma or papilloma reported as completely excised on core biopsy histopathologic analysis was upgraded. A predictive model combining radiology-pathology discordance, symptoms (palpable mass or nipple discharge), age ≥60, size ≥10 mm, and presence of ≥4 metachronous or concurrent peripheral papillomas achieved AUC 0.91, sensitivity 79%, and specificity 89% for upgrade. Selective surgery based on presence of any of these five factors, while excluding from surgery incidental papillomas and papillomas reported as completely excised on histopathology, would spare 294 of 612 lesions from routine excision, while identifying all 14 upgraded lesions. Conclusion: Benign non-atypical papillomas have a low malignancy upgrade rate; routine surgical excision may not be necessary. Selective excision is recommended for lesions satisfying any of the 5 criteria. Incidental papillomas or papillomas completely excised on histopathology may undergo imaging follow-up. Clinical Impact: The proposed criteria for selective surgery of benign papillomas on core biopsy would reduce surgeries without delaying diagnosis of malignancy.
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Limberg J, Kucher W, Fasano G, Hoda S, Michaels A, Marti JL. Intraductal Papilloma of the Breast: Prevalence of Malignancy and Natural History Under Active Surveillance. Ann Surg Oncol 2021; 28:6032-6040. [PMID: 33876349 DOI: 10.1245/s10434-021-09870-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The optimal management of intraductal papillomas (IPs) without atypia diagnosed on needle core biopsy (NCB) is unclear. This study analyzed the malignancy risk of immediately excised IPs and characterized the behavior of IPs under active surveillance (AS). METHODS We retrospectively reviewed the pathology and imaging records of patients diagnosed with IPs without atypia on NCB during a 10-year period (1999-2019). The malignancy upgrade rate was assessed in patients who had an immediate surgical excision, and the rates of both radiographic progression and development of malignancy were assessed in a cohort of patients undergoing AS. RESULTS The inclusion criteria were met in 152 patients with 175 IPs with a mean age of 51 ± 13 years. The average size of the IPs on initial imaging was 8 ± 4 mm. Most of the lesions (57%, n = 99) were immediately excised, whereas 76 (43%) underwent AS with interval imaging with a median follow-up period of 15 months (range, 5-111 months). Among the immediately excised IPs, surgical pathology revealed benign findings in 97% (n = 96) and ductal carcinoma in situ in 3% (n = 3). In the AS cohort, 72% (n = 55) of the IPs remained stable, and 25% (n = 19) resolved or decreased in size. At 2 years, 4% had increased in size on imaging and were subsequently excised, with ductal carcinoma in situ (DCIS, n = 1) and benign pathology (n = 1) noted on final pathology. CONCLUSIONS In a large series of breast IPs without atypia, no invasive carcinoma was observed after immediate excision, and 96% of the lesions had not progressed on AS. This suggests that patients with IP shown on NCB can safely undergo AS, with surgery reserved for radiographic lesion progression.
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Affiliation(s)
- Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Whitney Kucher
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Genevieve Fasano
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Syed Hoda
- Department of Pathology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Aya Michaels
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Jennifer L Marti
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
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Nuñez DL, González FC, Ibargüengoitia MC, Fuentes Corona RE, Hernández Villegas AC, Zubiate ML, Vázquez Manjarrez SE, Ruiz Velasco CC. Papillary lesions of the breast: a review. BREAST CANCER MANAGEMENT 2020. [DOI: 10.2217/bmt-2020-0028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Papillary breast lesions are rare breast tumors that comprise a broad spectrum of diseases. Pathologically they present as mass-like projections attached to the wall of the ducts, supported by fibrovascular stalks lined by epithelial cells. On mammogram they appear as masses that can be associated with microcalcifications. Ultrasound is the most used imaging modality. On ultrasound papillary lesions appear as homogeneous solid lesions or complex intracystic lesions. A nonparallel orientation, an echogenic halo or posterior acoustic enhancement associated with microcalcifications are highly suggestive of malignancy. MRI has proven to be useful to establish the extent of the lesion. Core needle biopsy is the gold standard for diagnosis. Surgical excision is usually recommended, although treatment for papillomas without atypia is still controversial.
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Affiliation(s)
- Denny Lara Nuñez
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernando Candanedo González
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mónica Chapa Ibargüengoitia
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Mariana Licano Zubiate
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Carlos Casian Ruiz Velasco
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Nakhlis F, Baker GM, Pilewskie M, Gelman R, Calvillo KZ, Ludwig K, McAuliffe PF, Willey S, Rosenberger LH, Parker C, Gallagher K, Jacobs L, Feldman S, Lange P, DeSantis SD, Schnitt SJ, King TA. The Incidence of Adjacent Synchronous Invasive Carcinoma and/or Ductal Carcinoma In Situ in Patients with Intraductal Papilloma without Atypia on Core Biopsy: Results from a Prospective Multi-Institutional Registry (TBCRC 034). Ann Surg Oncol 2020; 28:2573-2578. [PMID: 33047246 DOI: 10.1245/s10434-020-09215-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/17/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Available retrospective data suggest the upgrade rate for intraductal papilloma (IP) without atypia on core biopsy (CB) ranges from 0 to 12%, leading to variation in recommendations. We conducted a prospective multi-institutional trial (TBCRC 034) to determine the upgrade rate to invasive cancer (IC) or ductal carcinoma in situ (DCIS) at excision for asymptomatic IP without atypia on CB. METHODS Prospectively identified patients with a CB diagnosis of IP who had consented to excision were included. Discordant cases, including BI-RADS > 4, and those with additional lesions requiring excision were excluded. The primary endpoint was upgrade to IC or DCIS by local pathology review with a predefined rule that an upgrade rate of ≤ 3% would not warrant routine excision. Sample size and confidence intervals were based on exact binomial calculations. Secondary endpoints included diagnostic concordance for IP between local and central pathology review and upgrade rates by central pathology review. RESULTS The trial included116 patients (median age 56 years, range 24-82) and the most common imaging abnormality was a mass (n = 91, 78%). Per local review, 2 (1.7%) cases were upgraded to DCIS. In both of these cases central pathology review did not confirm DCIS on excision. Additionally, central pathology review confirmed IP without atypia in core biopsies of 85/116 cases (73%), and both locally upgraded cases were among them. CONCLUSION In this prospective study of 116 IPs without atypia on CB, the upgrade rate was 1.7% by local review, suggesting that routine excision is not indicated for IP without atypia on CB with concordant imaging findings.
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Affiliation(s)
- Faina Nakhlis
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | - Gabrielle M Baker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rebecca Gelman
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Katherina Z Calvillo
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | | | | | - Shawna Willey
- Georgetown University Cancer Center, Washington, DC, USA
| | | | | | | | - Lisa Jacobs
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Paulina Lange
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Stephen D DeSantis
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Stuart J Schnitt
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
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15
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Huang YY, Park H, McLaren S, Thirunavukkarasu P, Lin JTW, Rajakaruna R, Dhillon R, Ponniah AK. B3 lesion upgrade rates in a tertiary Australian breast centre: a 8-year experience (2012-2019). ANZ J Surg 2020; 90:2521-2526. [PMID: 32969161 DOI: 10.1111/ans.16315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/29/2020] [Accepted: 09/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND B3 breast lesions identified on core needle biopsy have uncertain malignant potential. Traditional management of these lesions has been surgical excision, but there is growing interest in less invasive and more cost-effective alternatives such as vacuum-assisted excisional biopsy (VAEB). Determining the rate of malignant upgrade for B3 lesions is important as it may identify low-risk lesions where VAEB could be considered. METHODS A retrospective study was conducted of women undergoing an elective excisional biopsy for a B3 lesion identified on core needle biopsy at a tertiary Australian breast centre. The pre-operative biopsy diagnosis and subsequent excisional biopsy diagnosis were used to calculate the proportion of cases where the diagnosis was upgraded to malignancy. RESULTS A total of 299 eligible patients were identified. Pre-operative diagnosis of papillary lesion with atypia was associated with the highest upgrade rate (50%, n = 12). The next highest upgrade rates occurred in those with flat epithelial atypia (37.50%, n = 8); atypical ductal hyperplasia (24.71%, n = 85); lobular carcinoma in situ (LCIS)/atypical lobular hyperplasia with calcification (17.65%, n = 17); and papillary lesion without atypia (4.72%, n = 106). Patients with radial scar (n = 51), classical LCIS without calcification (n = 7) and mucocoele-like lesion (n = 8) had a 0% upgrade rate. CONCLUSION VAEB may be appropriate for low malignant risk lesions such as papillary lesion without atypia, mucocoele-like lesion and radial scar lesion without atypia. Open-surgical-excisional biopsy remains appropriate for high upgrade lesions such as atypical ductal hyperplasia, papillary lesion with atypia, flat epithelial atypia and classical LCIS with calcification. Long-term prospective randomized multicentre studies and continuing multidisciplinary approach is recommended for future clinical implementation.
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Affiliation(s)
- Yang Y Huang
- Department of Breast Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hyerin Park
- Department of Surgery, The University of Western Australia, Faculty of Medicine, Dentistry and Health Sciences, Perth, Western Australia, Australia
| | - Sally McLaren
- Department of Anatomical Pathology, PathWest Laboratory Medical WA, Perth, Western Australia, Australia
| | - Palan Thirunavukkarasu
- Department of Breast Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Joshua T W Lin
- Department of Breast Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Ramela Rajakaruna
- Department of Anatomical Pathology, PathWest Laboratory Medical WA, Perth, Western Australia, Australia
| | - Ravinder Dhillon
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Ananda K Ponniah
- Department of Breast Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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16
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Li X, Gao H, Xu M, Wu Y, Gao D. Breast papillary lesions diagnosed and treated using ultrasound-guided vacuum-assisted excision. BMC Surg 2020; 20:204. [PMID: 32933518 PMCID: PMC7493139 DOI: 10.1186/s12893-020-00869-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/08/2020] [Indexed: 12/03/2022] Open
Abstract
Background The management of papillary lesions of the breast remains controversial, and thus, we assessed the value of vacuum-assisted excision (VAE)-guided ultrasound in the diagnosis and treatment of breast papillary lesions. Methods We retrospectively reviewed the data of 108 patients with papillary lesions diagnosed using VAE between August 2014 and January 2019. Cases without postoperative breast imaging in the follow-up were excluded, and 85 cases were eligible for the study. The follow-up period ranged from 6 to 53 months, with 38 months on average. All the papillary lesions were located away from the skin or nipple with a size less than or equal to 30 mm, and the lesions categorized as C2-4b were completely excised using VAE. All VAEs were performed using an 8-gauge vacuum-assisted biopsy needle under the guidance of ultrasound using a 10 MHz linear probe. Results Most patients with breast papillary lesions were asymptomatic (56.5%), and when the size of the breast papillary lesion was more than 20 mm on ultrasound imaging, atypical hyperplasia may have been concomitant. Breast lesions might have been pathologically diagnosed as papilloma after biopsy when they were categorized as BI-RADS 4a on ultrasound images. The rate of underestimation was 7.7% in papillary lesions diagnosed with VAE, and the recurrence rate of papilloma after VAE was low. Conclusions Breast papilloma was a common lesion on ultrasonographic screening, and VAE was applicable for completely excising small papillomas, even papillomas with atypical hyperplasia, to obtain an accurate diagnosis with a low rate of underestimation and recurrence. We believe that papilloma diagnosed by VAE might not require immediate excision, and imaging follow-up may be safe for at least 3 years.
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Affiliation(s)
- Xiaohui Li
- Nosocomial Infection Department, The Second Hospital, Shandong University Cheeloo College of Medicine, Jinan, 250033, China
| | - Hua Gao
- Department of Thoracic and General Surgery, Shandong Provincial Chest Hospital, Jinan, 250101, China
| | - Minling Xu
- Maternity and Child Care Center of DeZhou, DeZhou, 253015, China
| | - Yang Wu
- Department of Breast Surgery, The Second Hospital, Shandong University Cheeloo College of Medicine, No. 247, Beiyuandajie Street, Jinan, 250033, China
| | - Dezong Gao
- Department of Breast Surgery, The Second Hospital, Shandong University Cheeloo College of Medicine, No. 247, Beiyuandajie Street, Jinan, 250033, China.
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17
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Moseley T, Desai B, Whitman GJ, Robinson EK, Saunders T, Gonzalez A, He H. Benign Breast Intraductal Papillomas Without Atypia at Core Needle Biopsies: Is Surgical Excision Necessary? Ann Surg Oncol 2020; 28:1347-1355. [PMID: 32860176 DOI: 10.1245/s10434-020-09061-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 08/08/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of this study was to determine the upgrade rate of image-guided core needle biopsy (CNB)-proven benign breast intraductal papillomas (IDPs) without atypia to high-risk benign lesions or malignancy after surgical excision. METHODS A retrospective database search at a single institution identified 102 adult female patients with benign breast IDPs without atypia diagnosed on imaging-guided CNBs who subsequently had surgical excisions between 2011 and 2016. Patient characteristics, imaging features, biopsy techniques, and the pathology reports from imaging-guided CNBs and subsequent surgical excisions were reviewed. The upgrade rate to malignancies or high-risk benign lesions was determined at the patient level. RESULTS The upgrade rate to malignancy was 2.9% (3/102), including two cases of ductal carcinoma in situ (DCIS) and one case of microinvasive (< 1 mm) ductal carcinoma arising from DCIS. The upgrade rate to high-risk benign lesions was 7.8% (8/102), with seven cases of atypical ductal hyperplasia and one case of atypical lobular hyperplasia. A personal history of breast cancer and a larger mean lesion size were significantly associated with an upgrade to malignancy (p < 0.05). CONCLUSIONS The management of benign breast IDPs without atypia detected on imaging-guided CNBs is controversial. Our results suggest risk stratification is important in approaching these patients. Although surgical excision should be considered for all benign breast IDPs without atypia, observation with serial imaging may be appropriate in selected low-risk patients. This approach will save many women from surgeries and decrease the cost of medical care.
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Affiliation(s)
- Tanya Moseley
- Breast Imaging Section, Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bella Desai
- Breast Imaging Section, Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX, 77030, USA
| | - Gary J Whitman
- Breast Imaging Section, Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily K Robinson
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tamara Saunders
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Anneliese Gonzalez
- Division of Oncology, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hongying He
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX, 77030, USA.
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18
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Genco IS, Tugertimur B, Manolas PA, Hasanovic A, Hajiyeva S. Upgrade rate of intraductal papilloma without atypia on breast core needle biopsy: A clinical, radiological and pathological correlation study. Am J Surg 2020; 220:677-681. [PMID: 32007236 DOI: 10.1016/j.amjsurg.2020.01.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of the study was to determine the upgrade rate on excision of intraductal papilloma (IDP) without atypia diagnosed on breast core needle biopsy (CNB). METHODS We searched our pathology department database for breast CNB with a diagnosis of IDP from 2013 to 2018. The exclusion criteria included radiologic-pathologic discordance, atypia on the same CNB, absence of histologic slides to review or absence of excision information. Upgrade was defined as ductal carcinoma in situ (DCIS) or invasive cancer identified on excision. RESULTS 126 IDP without atypia cases from 94 patients were identified. The upgrade rate was 1.58% (2/126). Both upgrade cases showed DCIS with low and intermediate nuclear grade. Histologic size of IDP ≥1 cm was the only statistically significant predictor factor for an upgrade on excision. CONCLUSION The results suggest that non-surgical management of patients with radiologic-pathologic concordant IDP without atypia diagnosed on CNB may be appropriate in routine practice.
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Affiliation(s)
- Iskender Sinan Genco
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th street, New York, NY, 10075, USA.
| | - Bugra Tugertimur
- Northwell Health Lenox Hill Hospital, Department of Surgery, 100 E 77th street, New York, NY, 10075, USA
| | - Panagiotis A Manolas
- Northwell Health Lenox Hill Hospital, Department of Surgery, 100 E 77th street, New York, NY, 10075, USA
| | - Adnan Hasanovic
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th street, New York, NY, 10075, USA
| | - Sabina Hajiyeva
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th street, New York, NY, 10075, USA
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19
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MacColl C, Salehi A, Parpia S, Hodgson N, Ramonas M, Williams P. Benign breast papillary lesions diagnosed on core biopsy: upgrade rate and risk factors associated with malignancy on surgical excision. Virchows Arch 2019; 475:701-707. [PMID: 31372738 DOI: 10.1007/s00428-019-02626-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/24/2019] [Accepted: 07/15/2019] [Indexed: 11/27/2022]
Abstract
Evaluation of radiologically detected breast lesions is a common task in surgical pathology. Some benign lesions on biopsy are associated with an upgrade to in situ or invasive carcinoma on excision. The non-atypical breast papilloma has published upgrade rates of 0 to 29%. Traditionally, papillomas have been managed surgically, but the wide range of upgrade rates has raised uncertainty about the need for routine surgical excision. This study aims to identify risk factors associated with upgrade and determine the upgrade rate of non-atypical papillomas at our institution. In a retrospective review of pathology reports, we identified 266 patients with a diagnosis of benign papilloma on breast core biopsy. One hundred eighty-two patients underwent surgical resection. The final surgical pathology reports of all patients were reviewed and divided into one of two groups-benign or malignant. Twenty-one patients had a final diagnosis of in situ or invasive carcinoma, resulting in an upgrade rate of 12%. Radiologically detected lesions with calcifications were at higher risk for upgrade (OR = 4.45, 95% CI 1.08-18.27) than lesions without calcifications. Additionally, advanced patient age (OR = 1.07, 95% CI 1.03-1.13) and lesion size greater than 0.5 cm (OR = 2.59, 95% CI 0.38-17.48) was associated with upgrade to malignancy. Routine surgical excision of all papillomas is not recommended. Younger patients without high-risk features may benefit from clinical and radiologic follow-up alone. Accurate risk stratification will spare low-risk women unnecessary surgery.
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Affiliation(s)
- Christine MacColl
- Department of Pathology and Molecular Medicine, McMaster University Medical Center, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada.
- Department of Pathology and Molecular Medicine, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada.
| | - Amir Salehi
- Department of Pathology and Molecular Medicine, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Nicole Hodgson
- Department of Surgery, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Milita Ramonas
- Department of Radiology, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Phillip Williams
- Department of Pathology and Molecular Medicine, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
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20
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Choi HY, Kim SM, Jang M, Yun BL, Kang E, Kim EK, Park SY, Kim B, Cho N, Moon WK. Benign Breast Papilloma without Atypia: Outcomes of Surgical Excision versus US-guided Directional Vacuum-assisted Removal or US Follow-up. Radiology 2019; 293:72-80. [DOI: 10.1148/radiol.2019190096] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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21
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Kuehner G, Darbinian J, Habel L, Axelsson K, Butler S, Chang S, Chen R, Fehrenbacher L. Benign Papillary Breast Mass Lesions: Favorable Outcomes with Surgical Excision or Imaging Surveillance. Ann Surg Oncol 2019; 26:1695-1703. [DOI: 10.1245/s10434-019-07180-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Indexed: 11/18/2022]
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22
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Rageth CJ, O'Flynn EAM, Pinker K, Kubik-Huch RA, Mundinger A, Decker T, Tausch C, Dammann F, Baltzer PA, Fallenberg EM, Foschini MP, Dellas S, Knauer M, Malhaire C, Sonnenschein M, Boos A, Morris E, Varga Z. Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat 2018; 174:279-296. [PMID: 30506111 PMCID: PMC6538569 DOI: 10.1007/s10549-018-05071-1] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/23/2018] [Indexed: 11/24/2022]
Abstract
Purpose The second International Consensus Conference on B3 lesions was held in Zurich, Switzerland, in March 2018, organized by the International Breast Ultrasound School to re-evaluate the consensus recommendations. Methods This study (1) evaluated how management recommendations of the first Zurich Consensus Conference of 2016 on B3 lesions had influenced daily practice and (2) reviewed current literature towards recommendations to biopsy. Results In 2018, the consensus recommendations for management of B3 lesions remained almost unchanged: For flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL) and radial scars (RS) diagnosed on core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB), excision by VAB in preference to open surgery, and for atypical ductal hyperplasia (ADH) and phyllodes tumors (PT) diagnosed at VAB or CNB, first-line open surgical excision (OE) with follow-up surveillance imaging for 5 years. Analyzing the Database of the Swiss Minimally Invasive Breast Biopsies (MIBB) with more than 30,000 procedures recorded, there was a significant increase in recommending more frequent surveillance of LN [65% in 2018 vs. 51% in 2016 (p = 0.004)], FEA (72% in 2018 vs. 62% in 2016 (p = 0.005)), and PL [(76% in 2018 vs. 70% in 2016 (p = 0.04)] diagnosed on VAB. A trend to more frequent surveillance was also noted also for RS [77% in 2018 vs. 67% in 2016 (p = 0.07)]. Conclusions Minimally invasive management of B3 lesions (except ADH and PT) with VAB continues to be appropriate as an alternative to first-line OE in most cases, but with more frequent surveillance, especially for LN.
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Affiliation(s)
- Christoph J Rageth
- Département de Gynécologie et d'Obstétrique, Centre du sein, Hôpitaux Universitaires de Genève, Bd de la Cluse 30, 1211, Geneva 14, Switzerland. .,, Ringlikerstrasse 53, 8142, Uitikon Waldegg, Switzerland.
| | - Elizabeth A M O'Flynn
- The Rose Centre, St George's University Hospitals NHS Foundation Trust, Perimeter Road, London, SW17 0QT, UK
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY, 10065, USA
| | - Rahel A Kubik-Huch
- Department of Medical Services, Institute of Radiology, Kantonsspital Baden, im Ergel, 5404, Baden, Switzerland
| | - Alexander Mundinger
- Zentrum Radiologie der Niels-Stensen-Kliniken; Marienhospital Osnabrück, Bischofsstraße 1, 49074, Osnabrück, Germany
| | - Thomas Decker
- Institut für Pathologie am Dietrich-Bonhoeffer-Klinikum, Salvador-Allende-Straße 30, 17036, Neubrandenburg, Germany
| | - Christoph Tausch
- Brust-Zentrum Zürich, Seefeldstr. 214, 8008, Zurich, Switzerland
| | - Florian Dammann
- Interventional and Pediatric Radiology, Department of Diagnostic, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Pascal A Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Allgemeines Krankenhaus, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Eva Maria Fallenberg
- Department of Radiology, University Hospital, Ludwig Maximilian University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maria P Foschini
- Department of Biomedical and Neuromotor Sciences, Unit of Anatomic Pathology at Bellaria Hospital, University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Sophie Dellas
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Michael Knauer
- Breast Center St. Gallen, Cantonal Hospital St. Gallen, Rorschacher Str. 95, 9007, St. Gallen, Switzerland
| | - Caroline Malhaire
- Imaging Department, Institut Curie, PSL Research University, Paris, France
| | - Martin Sonnenschein
- Division of Radiology, Breast Center Bern (Brustzentrum Bern), Klinik Engeried, Lindenhofgruppe AG, Riedweg 15, 3012, Bern, Switzerland
| | - Andreas Boos
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland
| | - Elisabeth Morris
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY, 10065, USA
| | - Zsuzsanna Varga
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland Schmelzbergstrasse 12., 8091, Zurich, Switzerland
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23
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Rasmussen BB, Balslev E, Jarle Christensen I, Lanng C, Bak A, Galatius H, Møller Talman ML, Sharghi Someh N, Vejborg I, Okholm M. Diagnostic challenges in clinical, radiological and histopathological tests regarding papillomatous lesions of the breast. Breast 2018; 40:177-180. [DOI: 10.1016/j.breast.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 05/07/2018] [Accepted: 05/12/2018] [Indexed: 11/27/2022] Open
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24
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Leithner D, Kaltenbach B, Hödl P, Möbus V, Brandenbusch V, Falk S, Park C, Vogl TJ, Müller-Schimpfle M. Intraductal Papilloma Without Atypia on Image- Guided Breast Biopsy: Upgrade Rates to Carcinoma at Surgical Excision. Breast Care (Basel) 2018; 13:364-368. [PMID: 30498423 DOI: 10.1159/000489096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background The management of intraductal papilloma without atypia (IDP) in breast needle biopsy remains controversial. This study investigates the upgrade rate of IDP to carcinoma and clinical and radiologic features predictive of an upgrade. Methods Patients with a diagnosis of IDP on image-guided (mammography, ultrasound, magnetic resonance imaging) core needle or vacuum-assisted biopsy and surgical excision of this lesion at a certified breast center between 2007 and 2017 were included in this institutional review board-approved retrospective study. Appropriate statistical tests were performed to assess clinical and radiologic characteristics associated with an upgrade to malignancy at excision. Results For 60 women with 62 surgically removed IDPs, the upgrade rate to malignancy was 16.1% (10 upgrades, 4 invasive ductal carcinoma, 6 ductal carcinoma in situ). IDPs with upgrade to carcinoma showed a significantly greater distance to the nipple (63.5 vs. 36.8 mm; p = 0.012). No significant associations were found between upgrade to carcinoma and age, menopausal status, lesion size, microcalcifications, BI-RADS descriptors, initial BI-RADS category, and biopsy modality. Conclusion The upgrade rate at excision for IDPs diagnosed with needle biopsy was higher than expected according to some guideline recommendations. Observation only might not be appropriate for all patients with IDP, particularly for those with peripheral IDP.
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Affiliation(s)
- Doris Leithner
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt/M., Germany
| | - Benjamin Kaltenbach
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt/M., Germany
| | - Petra Hödl
- Institute of Pathology, Klinikum Frankfurt Höchst, Frankfurt/M., Germany
| | - Volker Möbus
- Department of Obstetrics and Gynecology, Klinikum Frankfurt Höchst, Frankfurt/M., Germany
| | - Volker Brandenbusch
- Mammography Screening, Diagnostic Breast Center Turmcarée, Frankfurt/M., Germany
| | - Stephan Falk
- OptiPath, Pathology Associates, Frankfurt/M., Germany
| | - Clara Park
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt/M., Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt/M., Germany
| | - Markus Müller-Schimpfle
- Institute of Radiology (RZI), Klinikum Frankfurt Höchst, Academic Teaching Hospital of the University of Frankfurt, Frankfurt/M., Germany
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25
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Kiran S, Jeong YJ, Nelson ME, Ring A, Johnson MB, Sheth PA, Ma Y, Sener SF, Lang JE. Are we overtreating intraductal papillomas? J Surg Res 2018; 231:387-394. [PMID: 30278958 DOI: 10.1016/j.jss.2018.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/21/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The management of intraductal papillomas (IDPs) diagnosed on core needle biopsy (CNB) remains controversial regarding whether excision is required. We evaluated whether excision of IDPs might be overtreatment based on a consecutive patient population where all IDPs were routinely excised. MATERIALS AND METHODS We retrospectively reviewed the records of consecutive patients treated with excision of IDPs at our institution from 2009 to 2016. We evaluated the rate of upgrade of IDPs on CNB and factors predicting for malignant upgrade. RESULTS Of 153 CNB specimens, 136 (88.9%) were IDPs without atypia and 14 (9.2%) showed atypia. The overall upgrade rate on final pathology was 7.3% with 1.3% for invasive cancer, 2.7% for ductal carcinoma in situ, and 3.3% for atypical ductal hyperplasia. Of the 14 patients with atypia on CNB, two of these patients (14.2%) were found to have ductal carcinoma in situ. In the absence of atypia on CNB, upgrade rates were 1.5% for invasive and 1.5% for in situ carcinoma. Personal history of breast cancer and magnetic resonance imaging-guided biopsy predicted for malignant upgrade. CONCLUSIONS IDPs on CNB have a low chance of harboring an occult malignancy. Given the low probability of upgrade to invasive breast cancer, it is reasonable to consider watchful surveillance in the absence of a prior personal history of breast cancer or atypia on CNB.
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Affiliation(s)
- Sayee Kiran
- Division of Breast, Endocrine and Soft Tissue Surgery, Department of Surgery, Norris Comprehensive Cancer Center and Los Angeles County + USC Medical Center, University of Southern California, Los Angeles, California
| | - Young Ju Jeong
- Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Maria E Nelson
- Division of Breast, Endocrine and Soft Tissue Surgery, Department of Surgery, Norris Comprehensive Cancer Center and Los Angeles County + USC Medical Center, University of Southern California, Los Angeles, California
| | - Alexander Ring
- Division of Breast, Endocrine and Soft Tissue Surgery, Department of Surgery, Norris Comprehensive Cancer Center and Los Angeles County + USC Medical Center, University of Southern California, Los Angeles, California
| | - Meade B Johnson
- Department of Radiology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Pulin A Sheth
- Department of Radiology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Yanling Ma
- Department of Pathology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Stephen F Sener
- Division of Breast, Endocrine and Soft Tissue Surgery, Department of Surgery, Norris Comprehensive Cancer Center and Los Angeles County + USC Medical Center, University of Southern California, Los Angeles, California
| | - Julie E Lang
- Division of Breast, Endocrine and Soft Tissue Surgery, Department of Surgery, Norris Comprehensive Cancer Center and Los Angeles County + USC Medical Center, University of Southern California, Los Angeles, California.
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Nasehi L, Sturgis CD, Sharma N, Turk P, Calhoun BC. Breast Cancer Risk Associated With Benign Intraductal Papillomas Initially Diagnosed on Core Needle Biopsy. Clin Breast Cancer 2018; 18:468-473. [PMID: 30017794 DOI: 10.1016/j.clbc.2018.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/07/2018] [Accepted: 06/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The long-term risk for patients with benign intraductal papillomas (IDPs) on core needle biopsy (CNB) who are not upgraded on excision is not well-defined. The goal of this study was to determine the cumulative breast cancer (BC) incidence for patients with benign IDP on CNB. MATERIALS AND METHODS There were 152 benign IDPs diagnosed on CNB between 2003 and 2008. Radiology and pathology data were reviewed by breast radiologists and pathologists. Clinical follow-up was obtained from the electronic medical record (Epic). RESULTS Excision results were: 96 (63%) not upgraded, 9 (6%) with BC on excision (6 ductal carcinoma in situ, 3 invasive carcinoma), and 5 (3%) lacked correlation with the CNB site. Excision reports were unavailable for 42 (28%). Excluding cases with Breast Imaging Reporting and Data System (BI-RADS) 5 or discordant imaging, there were 6 (4%) true upgrades (all ductal carcinoma in situ). After the exclusion of patients with other major risk factors, follow-up was available for 55 of 58 patients with benign IDPs, and 8 (14%) developed BC after a median of 112 months (range, 11-159 months). None of the benign IDP patients without an excision report developed BC after a median of 97 months (range, 5-164 months). CONCLUSIONS The upgrade rate for benign IDP diagnosed on CNB was 4%, similar to recent studies. The cumulative BC incidence for those who were not upgraded and who had no history of BC was 14% at a median of 9 years. When combined with patients without an excision pathology report, the overall BC incidence was 9%. The findings support continued breast cancer surveillance in this patient population.
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Affiliation(s)
- Leyla Nasehi
- Department of Breast Imaging, Imaging Institute, Cleveland Clinic, Cleveland, OH
| | - Charles D Sturgis
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Nidhi Sharma
- Department of Breast Imaging, Imaging Institute, Cleveland Clinic, Cleveland, OH
| | - Paulette Turk
- Department of Breast Imaging, Imaging Institute, Cleveland Clinic, Cleveland, OH
| | - Benjamin C Calhoun
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH.
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Zaleski M, Chen YA, Chetlen AL, Mack J, Xu L, Dodge DG, Karamchandani DM. Should we excise? Are there any clinical or histologic features that predict upgrade in papillomas, incidental or non-incidental? Ann Diagn Pathol 2018; 35:62-68. [PMID: 29793212 DOI: 10.1016/j.anndiagpath.2018.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/10/2018] [Indexed: 10/16/2022]
Abstract
The clinical decision to excise intraductal papilloma (IDP) without atypia diagnosed on biopsy remains controversial. We sought to establish clinical and histologic predictors (if any) which may predict upgrade in IDP. 296 biopsies (in 278 women) with histologic diagnosis of IDP without atypia were retrospectively identified and placed into Incidental (no corresponding imaging correlate), or Non-incidental (positive imaging correlate) groups. 253/296 (85.5%) cases were non-incidental, and 43/296 (14.5%) were incidental. 73.1% (185/253) non-incidental and 48.8% (21/43) incidental cases underwent excision. 12.4% (23/185) non-incidental cases underwent an upgrade to cancer or high-risk lesion; namely 8-Ductal carcinoma in situ (DCIS), 8-atypical ductal hyperplasia (ADH), 6-lobular neoplasia, and 1-flat epithelial atypia. There was no histopathologic feature on the biopsy in the non-incidental group which predicted upgrade; however a past history of atypia was significantly associated with upgrade. 2 of the 21 incidental cases upgraded (1 to ADH and 1 to lobular neoplasia); the former had a past history of ADH. Both incidental upgrades were >1 mm in size, and were not completely excised on the biopsy. None of the incidental cases which appeared completely excised on biopsy upgraded, irrespective of the size on biopsy. These findings suggest that all non-incidental IDPs should be considered candidates for surgical excision, given the 12.4% upgrade rate and no definitive histologic predictors of upgrade. Patients with incidental IDPs (if <1 mm, completely excised on biopsy and with no history of high risk breast lesion) can be spared excision.
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Affiliation(s)
- Michael Zaleski
- Department of Pathology, Division of Anatomic Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Yun An Chen
- Penn State College of Medicine, Hershey, PA, United States
| | - Alison L Chetlen
- Department of Radiology, Division of Breast Imaging, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Julie Mack
- Department of Radiology, Division of Breast Imaging, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Liyan Xu
- Department of Pathology, Duke University, Durham, NC, United States
| | - Daleela G Dodge
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Dipti M Karamchandani
- Department of Pathology, Division of Anatomic Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States.
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28
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Abstract
PURPOSE OF REVIEW The aim of this review is to summarize recently published literature addressing atypical ductal hyperplasia (ADH), lobular neoplasia (atypical lobular hyperplasia [ALH] and classic lobular carcinoma in situ [C-LCIS]), non-classic lobular carcinoma in situ (NC-LCIS), papillary lesions, and flat epithelial atypia (FEA). RECENT FINDINGS While ADH, ALN, and C-LCIS are well-established markers of an increased risk of future breast cancers, the risk implications are less clear for papillary lesions and FEA. NC-LCIS is the least well-characterized lesion, with scant published literature on its natural history and surgical management when encountered on needle biopsy. Recent data suggest that lobular neoplasia on core biopsy of a BI-RADS ≤ 4 concordant lesion does not require an excision, while ADH, atypical papillomas, and NC-LCIS should be excised. Evidence on FEA and papillomas without atypia suggests a low risk of upgrade on excision, and prospective studies on the upgrade of these lesions are ongoing.
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Affiliation(s)
- Faina Nakhlis
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA. .,Surgical Oncology, Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, 450 Brookline Ave., Boston, MA, 02115, USA.
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29
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Han SH, Kim M, Chung YR, Yun BL, Jang M, Kim SM, Kang E, Kim EK, Park SY. Benign Intraductal Papilloma without Atypia on Core Needle Biopsy Has a Low Rate of Upgrading to Malignancy after Excision. J Breast Cancer 2018; 21:80-86. [PMID: 29628987 PMCID: PMC5880969 DOI: 10.4048/jbc.2018.21.1.80] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/05/2018] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The management of benign intraductal papilloma (IDP) without atypia diagnosed on core needle biopsy (CNB) remains controversial. This study was performed to evaluate the rate of upgrading to malignancy or high-risk lesions after excision and to identify factors associated with upgrading using a large series of benign IDP cases without atypia. METHODS We included patients who were diagnosed as having benign IDP without atypia on CNB and underwent surgical or vacuum-assisted excision between 2010 and 2015. We analyzed the clinical, radiologic, and histopathologic features of IDPs that were upgraded to malignancy or high-risk lesions after excision. RESULTS A total of 511 benign IDPs without atypia diagnosed via CNB were identified, of which 398 cases were treated with excision. After reviewing these cases, four cases of high-risk lesions in adjacent tissue on CNB, two cases which were revealed as papilloma with atypia, and nine cases of malignancy in the same breast were excluded. In the remaining 383 cases, the rate of upgrading to malignancy and high-risk lesions after excision was 0.8% and 4.4%, respectively. The presence of concurrent contralateral breast cancer, the presence of symptoms, and multifocality were factors significantly associated with upgrading to malignancy on subsequent excision. Surgical excision rather than vacuum-assisted excision was significantly associated with upgrading to high-risk lesions or malignancy. CONCLUSION The rate of upgrading to malignancy for benign IDP without atypia was very low, suggesting that close clinical and radiologic observation may be sufficient for patients with benign IDP without atypia on CNB under proper settings.
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Affiliation(s)
- Song-Hee Han
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Pathology, Konyang University Hospital, Daejeon, Korea
| | - Milim Kim
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yul Ri Chung
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Bo La Yun
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Mijung Jang
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sun Mi Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eunyoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eun-Kyu Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - So Yeon Park
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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